Fillable Printable Form 54087
Fillable Printable Form 54087
Form 54087
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RULE 6 NOTICE OF TERMINATION/EXCLUSION
(NOT/E) LETTER
State Form 54087 (11-09)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTE:Storm water run-off associated with industrial activity NPDES General Permit.
Rule 327 IAC 15 (rule 6). Please read all instructions before completing this
form.
Return this form by mail to the Indiana Department of Environmental
Management, Rule 6 Coordinator at the address listed in the box on the
upper-right
This NOT/E Letter must be completed and submitted to the Indiana
Department of Environmental Management within thirty (30) days of the
date of closure or transfer.
This form must be submitted with the required additional information for
all facilities claiming an exclusion from Rule 6 permit coverage.
For questions regarding this form and
requirements for permit
termination/exclusion, contact:
IDEM – Rule 6 Coordinator
100 North Senate Avenue
Mail Code 65-42 Room 1255
Indianapolis, IN 46204
Phone: (317) 233-0202 or
(800) 451-6027, ext. 30202 (within Indiana)
Web Access:
www.idem.IN.gov/4901.htm
PART A: GENERAL INFORMATION FOR FACILITY
1. Facility permit number
2. Facility name
3. Facility address (number and street)
City ZIP code County
PART B: GENERAL INFORMATION FOR RESPONSIBLE INDIVIDUAL
4. Responsible individual name (Last, first, middle)
5. Responsible individual title
6. Responsible individual mailing address (number, street, P.O. Box)
City State ZIP code
7. Responsible individual telephone number
8. Responsible individual FAX number
9. Responsible individual e-mail address
PART C: TERMINATION/EXCLUSION INFORMATION
10.Date facility intends to terminate permit (mm, dd, yyyy)
By submitting this application and claiming a termination/exclusion you are certifying that the facility no
longer authorized to discharge storm water associated with the industrial activity in accordance with 327 IAC
15-6. Discharging storm water associated with industrial activity to waters of the state is unlawful and is not
authorized by an NPDES permit.
(Check the appropriate box below for which the termination/exclusion is being requested.)
Closure of the facility.
If applicable, the new owner or operator must submit a new Notice of Intent within sixty (60) days of the
date of closure.
Transfer of ownership or operations
The new owner or operator must submit a new Notice of Intent within sixty (60) days of the date of
transfer. If this option for termination is selected, please provide the new owner/operator’s contact
information in items 11-14. Items 11-14 must be completed in order for your termination to be valid.
No exposure of all facility industrial activities exposed to storm water.
A complete “No Exposure Certification” form (U.S. EPA Form 3510-11(10-99) referenced in
327 IAC 15-6-12 (b)(1) must be submitted with this form.
All storm water run-off from the facility flows into a combined sewer system
A certification letter from the responsible party of the combined sewer system, on responsible party
letterhead, must be submitted with the form.
Reset Form
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PART C: TERMINATION/EXCLUSION INFORMATION (continued)
An individual permit has been issued for the facility. Storm water run-off associated with
industrial activities is incorporated into the permit
The permit number assigned to the facility is
A condition of “no discharge” of storm water run-off exists.
Check the condition that is being claimed for the facility
The facility does not have a point source discharge.
The run-off from the facility does not discharge to a “water of the state.”
In addition to this form, the operator/owner of the facility must submit:
•A site map that shows the property boundaries, areas of industrial activity, storm water flow direction
(represented by arrows), local water bodies (including the distance of the facility from rivers,
streams, ponds, ditches, etc), and identification of adjacent properties (farmland, residential, etc.).
•Location of any facility drinking water wells or the location of any private drinking wells that are
located within ¼ mile of the property boundary of the facility (only applies to claims of no discharge
based on infiltration).
To claim that a facility meets one of the conditions above, the “responsible individual” should carefully
evaluate the operations at the facility as well as all potential discharge points. If there is a potential for
storm water discharge, the “responsible individual” should not file termination and continue to operate
the facility in accordance with 327 IAC 15-6 and all other applicable permits.
A claim of “no discharge” under one of the conditions listed above will be evaluated by the agency. This
will be accomplished through an on-site inspection of the facility to verify that the claim is valid. In
addition, the agency may request additional information from the “responsible individual” that has filed a
claim of “no discharge”.
11.New facility name
12.New facility responsible individual
13.New facility responsible individual telephone number
14.New facility responsible individual address (number and street)
City
State
ZIP code
PART D: CERTIFICATION AND SIGNATURE
“I certify under penalty of law that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of my
knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fine and imprisonment for knowing violations.
Signature of responsible corporate officer or duly authorized representative under 327 IAC 15-4-3(g)
Print name _________________________________________
Title _______________________________
Signature __________________________________________
Date (mm/dd/yyyy) ___________________
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INSTRUCTIONS FOR COMPLETING RULE 6 NOTICE OF TERMINATION/EXCLUSION (NOT/E) LETTER
GENERAL
By completing and submitting this form you are certifying to IDEM that your facility, cited in Part A, is no longer
discharging storm water associated with industrial activity.
All information on this application must be complete and where appropriate supporting documentation must be
attached and submitted with the form. Incomplete applications will be denied termination or exclusion until the
required information is submitted and your application is complete.
The agency may schedule an inspection of the facility to verify claims of termination/exclusion are valid.
PART A: GENERAL INFORMATION FOR FACILITY
1. Enter the facility’s permit identification number as assigned by IDEM. If you do not know the permit
identification number, you can find it on the Notice of Sufficiency (NOS) Letter from IDEM responding to
your most recent Notice of Intent (NOI) application. Leave this item blank if the facility does not have an
active Rule 6 permit and is filing for exclusion.
2. Enter the facility’s name as listed on your most recent Notice of Intent application.
3. Enter the facility’s street address, city, county, and ZIP code.
PART B: GENERAL INFORMATION FOR RESPONSIBLE INDIVIDUAL
4-9 Enter the responsible individual’s name and corresponding information. Responsible individual means:
(A) For a corporation, by a responsible corporate officer. As used in this section, "responsible corporate
officer" means:
(i) a president, secretary, treasurer, any vice president of the corporation in charge of a principal
business function, or any other person who performs similar policy or decision making
functions for the corporation; or
(ii) the manager of one (1) or more manufacturing, production, or operating facilities employing
more than two hundred fifty (250) persons or having gross annual sales or expenditures
exceeding twenty-five million dollars ($25,000,000) (in second quarter 1980 dollars), if
authority to sign documents has been assigned or delegated to the manager in accordance
with corporate procedures.
(B) For a partnership or sole proprietorship, by a general partner or the proprietor, respectively.
(C) For a municipality, state, federal, or other public agency or political subdivision thereof, by either a
principal executive officer or ranking elected official.
PART C: TERMINATION/EXCLUSION INFORMATION
10. Enter the date (dd/mm/yyyy) the facility ceased operations and no longer had any significant materials
remaining on-site and exposed to storm water.
Indicate the reason for submitting this NOT/E Letter by checking the appropriate box and submitting
the required addendum in concurrence with this form.
11-14 If the transfer of ownership option for termination is selected, please provide the new owner/operator’s
contact information. These items must be completed in order for your termination to be valid.
PART D: CERTIFICATION AND SIGNATURE
This statement should be read carefully by the permittee(s). The responsible official or authorized
representative of the operator (and owner, if the owner has co-permittee status) shall print their names for
clarity, then sign and date the document on the lines provided.
